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    The Socialist Health Association is appalled by reports that Kate Bingham, who heads up Boris Johnson’s vaccine taskforce, has charged the government £670,000, for what is described as a ’team of boutique relations consultants.’ Each consultant is reportedly paid £167,000 a year – more than the Prime Minister. There appears to have been no formal process to appoint Bingham to chair Britain’s vaccine taskforce.

    This would appear to be a gross waste of public funds, which are desperately needed to fight the Covid pandemic.

    The Sunday Times reported that Bingham had shared government documents to investors at a $200-a-head virtual conference – an appearance that was not signed off by ministers. At the same time, she manages private investments in companies developing coronavirus drugs.

    We note that Ms Bingham, a venture capitalist, is married to Jesse Norman, a Tory Treasury minister, which only underlines the potential conflicts of interest.

    The SHA calls for the pandemic to be fought through the NHS and other public bodies, and not to be outsourced to private interests.

    https://www.thelondoneconomic.com/politics/kate-bingham-vaccine-tsar-runs-up-670000-taxpayer-funded-pr-bill/08/11/

    1 Comment

    SHA Cymru fully supports the actions of the First Minister and the Welsh Government in their management of the current crisis resulting from COVID 19. During this time SHA officers have had opportunities to meet with a number of Welsh Ministers. We have been impressed with the sheer amount of work they are undertaking and by the collegiate and thoughtful style they have adopted.
    The decision-making process has been clear, evidenced based, and methodical. It stands in sharp contrast to the vacillation of the Prime Minister and his Cabinet. We take some confidence from this that Wales and its people will emerge from the pandemic knowing that the Welsh Government, using scientific evidence available to them at the time, aimed to reduce further significant loss of lives and huge damage to the Welsh economy.

    Any questions or comments to Tony Beddow, tonesue@aol.com

    2 Comments

    This week North West council leaders and MPs wrote to the Chancellor asking him to set out plans for what comes next once this lockdown is over. We have been through so much change and uncertainty we deserve to know what lies ahead so we can plan.

    Today, Sunak announced that the furlough scheme will continue at 80% until March. We succeeded in pushing him to give workers what they deserve, not the 13% less that he thought the North was worth.

    This is what we can achieve when we work together and hold the government to account.

    Posted by Jean Hardiman Smith on behalf of Team North West

    Comments Off on Update from Labour Team North West

    We  are  writing to you in response to the apparently hurried decision to begin population-wide testing in Liverpool, as part of the £100 + billion ‘Operation Moonshot’, in order to “find positive cases and to break chains of transmission” (Government Press Release, 3rd November 2020).

    This announcement is inconsistent with the SAGE advice at its 56th meeting on 10 September 2020 that it had “high confidence” that “Prioritising rapid testing of symptomatic people is likely to have a greater impact on identifying positive cases and reducing transmission than frequent testing of asymptomatic people in an outbreak area”. This chimes with WHO guidance to focus on contact tracing and identification of clusters, and which does not recommend mass screening.  Proposals for mass screening in their current form will undermine this priority.  

    Searching for symptomless yet infectious people is like searching for needles that appear transiently in haystacks. The potential for harmful diversion of resources and public money is vast. Also of concern are the potential vested interests of commercial companies supplying new and as yet inadequately evaluated tests. If the programme is to proceed, then the contracts awarded, or advertised, should be made public, including their cost to the public purse. (The government is already facing a judicial review for failing to publish covid-19 contracts, brought by your fellow MPs Debbie Abrahams, Layla Moran and Caroline Lucas with the Good Law Project.)

     There is currently no evidence demonstrating that SARS-CoV-2 screening can bring benefit cost-efficiently, and experience shows that unless screening is delivered as a systematic programme with quality assurance for every step of the pathway then any theoretical benefit will not be realised in practice, even where a benefit is possible.

    We would like to ask you what has been decided, and how were decisions reached, regarding the types of tests to be used, what exactly are they aiming to detect, and how has their accuracy been evaluated?  We understand that the Liverpool pilot is likely to use a direct LAMP test (Optigene) and a lateral flow assay (Innova). Currently there is little or no evidence of the accuracy of either of these tests from their use in presymptomatic and asymptomatic cases, or in field settings.  There is substantial uncertainty as to whether they can detect the lower viral loads that are likely in symptomless people, which appears to be the aim of this mass pilot.  If the tests fail to detect cases, then the programme will waste resources and time, and give people false reassurance which could increase transmission.   Similarly, the false positive rates of these tests have not been established in community use and neither have the implications for contact tracing services.  Evaluations of other similar tests by the WHO has suggested between 1% and 5% of people without infection may get false positive findings.  This means that if 1 in 100 people tested in the pilot have asymptomatic infections, as few as 1 in 5 of those getting positive results will actually have Covid-19 – and 4 out of 5 would be false positives and they and their contacts would unnecessarily be told to isolate.

    The accuracy of tests for identifying symptomless infection in a healthy population need to be evaluated in a pilot study with proper research design to assess the extent to which asymptomatic people contribute to overall case-loads, whether they play a significant role in transmission, and whether screening can help. We see no evidence that the Liverpool has such a research design.

    It appears unclear what will happen when people test positive, and negative, whether there will be clinical oversight in interpretation of the results and whether the results will be sent to patients’ GPs and integrated with medical records. What will people be offered? What will they be instructed to do? What support structures are in place to achieve this? It is also unclear how this programme will be integrated into, and affect, the track and trace system, which is already performing poorly.

    Are all the above considerations documented in a format suitable for the lay public to understand as part of an opt-in informed consent process? Is there an option to withdraw from the scheme at any stage, including freeing people of any study requirements? Are participants afforded the right to access their information, to know with whom it is being shared, and to request its deletion – in line with GDPR and the Data Protection Act?

    These are just some of the questions and issues that are concerning us and that need to be pursued, along with asking the government to explain why they are acting inconsistently with SAGE’s advice. We urge you to do so as soon as possible.

    If we can be of any assistance, please do not hesitate to contact us.

    Yours sincerely,

    Allyson Pollock

    Professor of Public Health, Newcastle University

    Anthony J. Brooks

    Professor of Genomics and Bioinformatics, Leicester University

    Louisa Harding-Edgar, General Practitioner and Academic Fellow in General Practice. Glasgow University

    Angela E. Raffle, Consultant in Public Health, Honorary Senior Lecturer in Public Health, Bristol Medical School Department of Population Health Sciences, University of Bristol

    Stuart Hogarth, Lecturer, Department of Sociology, University of Cambridge.

    Comments Off on Asymptomatic Covid-19 screening in Liverpool
    Biomedical scientists in the frontline of Covid-19 testing at a Lancashire NHS trust are losing about £7,000-a-year because hardline bosses refuse to pay ‘the going rate for the job’.
    Unite, Britain and Ireland’s largest union, said that the Lancashire Teaching Hospitals NHS Foundation Trust is facing a retention crisis as underpaid biomedical scientists are voting with their feet and moving to other trusts in the north west that pay the correct Agenda for Change (AfC) pay rate.
    Now the 13 biomedical scientists, who carry out vital tests once patients have been admitted to hospital with Covid-19, will be balloted from Monday 9 November for strike action or industrial action short of a strike. The ballot closes on Thursday 19 November.
    The crux of the dispute is that the biomedical scientists have been held back on Band 5 (AfC), despite qualifying for Band 6 (just under £38,000-a-year) due to working unsupervised for a number of years. The majority of Unite’s 13 members have lost about £7,000 annually as Band 5 pays about £30,000.
    Unite regional officer Keith Hutson said: “Our biomedical scientists have had years of training and are highly skilled, but are not paid a fortune. They are in the frontline of carrying Covid-19 related tests once patients are admitted to hospital.
    “Yet, we have a hardline trust management that is not prepared to pay ‘the going rate for the job’ for essential NHS workers at a time of national emergency.
    “This issue has been dragging on for over a year. At the start of the pandemic earlier this year, our members, as an act of good faith, put this dispute on the backburner.
    “When the number of infections dropped in the summer, we raised this issue again – but have been met by a brick wall from a skinflint management. Our members are being ripped off and short-changed which is not a great advert for this trust.
    “The result is that we have a retention crisis at the Lancashire Teaching Hospitals NHS Foundation Trust as our members are voting with their feet and move to trusts, such as in Blackpool and Blackburn, which appreciate their skills and dedication during this challenging time for the NHS – and pay the proper rate for the job.
    “Now, reluctantly, our members will be balloted for industrial action. However, there is a generous window of opportunity for the management to resolve this dispute and Unite’s door is open 24/7 for constructive talks.”
    The trust covers Chorley and South Ribble Hospital, and the Royal Preston Hospital.
    Shaun Noble
    Unite senior communications officer 
    Comments Off on Biomedical scientists carrying out Covid-19 tests at Lancashire NHS trust ‘short-changed’ by £7,000-a-year

    What Impact Will the Second National Covid-19 Lockdown Have On Reducing Covid-19 Deaths?

    This of course must be one of the key questions. Seemingly no-one wants to predict a future lockdown-induced death rate figure. It’s probable that the Covid-19 death rate will not fall in November 2020 as those about to die will already be infected, unwell and in hospital. Some have estimated that the lockdown might cut down the Covid-19 infection rate by up to 75%. But with hospitals filling up with Covid-19, patients needing care for cancer, strokes and heart attacks might have their treatment delayed or cancelled resulting in an increase in non-Covid-19 deaths.

    The exact nature of the lockdown is being disputed by some. Schools do seem to be a breeding ground for spreading infection. In Ealing of the 98 state-funded schools 70 of them have Covid-19 cases. Is keeping the schools open such a clever thing to do? Most pubs and restaurants have invested money, time and continuing efforts in making their facilities compliant with Covid-19 restriction. There is scant evidence that they are prime areas for Covid-19 spreading. Closing them all down for at least a month could finally finish off those businesses that don’t own their properties, and will damage the ‘social’ health of their customers.

    There are, of course, increasingly alternative voices who are saying that the lockdown will not save lives but just delay Covid-19 deaths. This lockdown could go on for months, and might be followed by a series of lockdowns – until a successful vaccine is universally available. This would destroy the economy and create huge financial, employment, social, housing, mental health and physical health problems. NHS services would be decimated.

    The lockdown might be buying us time – but at what cost?

    MENTAL HEALTH

    £400 Million Announced to Revamp Mental Health Facilities

    This initiative is aimed at replacing ‘dormitories’ with en-suite rooms. 21 NHS mental health Trusts have apparently been identified to receive the first tranche of grant funding. Sadly the two NHS North West London mental health Trusts are not on this list.

    Also, of the 40 ‘new’ NHS hospitals recently announced by Prime Minister Johnson only two of them will be mental health facilities.

    £250 Million committed to Introducing Mental Health Support in Schools by 2023

    The targets are to cover 25% of England (1.5 million children) by 2023 and for CAMHS to see 345,000 young people by 2023/24. (CAMHS stands for Child and Adolescent Mental Health Services).

    2016 to Date the English NHS Mental Health Workforce has Increased by 13,860

    So said Claire Murdoch at the 20 October 2020 Health and Social Care Select Committee meeting. She ought to know as she is the NHS England (NSHE) Mental Health Director. If you find that figure hard to believe, what is more believable is the number of the extra mental health staff she thinks are needed by 2023. It’s 20,000. This would cast £2.3 billion – if the staff could actually be found.

    NHSE Announces £15 Million Mental Health Support for Covid-19 Nurses and Support Staff

    Claire Murdoch again rather coyly adds that in order to supply the service ‘we will be working with another provider’. Presumably what she means is a private company.

    Mental Health ‘999’ Police Call Outs Up by 41% in Five Years in England

    After years of the Police saying how inappropriate it is for them to deal with the mentally ill, answers to a Freedom of Information request have revealed 301,1444 reported incidents in 2019. In 2015 the figure was 213,513. The biggest increases were in Wiltshire and Lancashire.

    The Royal College of Psychiatrists disclosed in October 2020 that 40% of those waiting for mental health support ended up seeking help from emergency and crisis services.

    NHS Test and Trace

    If it wasn’t so tragic it might be amusing. Just how much longer can Baroness Harding hang on as NHS Test and Trace boss? On 27 October 2020 ‘The Independent’ reported that the Sitel software is clearly not that robust. On Sunday 25 October there was a system fault which resulted in Covid-19 cases not being scheduled for clinical assessment and contact tracing. The fault was still in play on the following day.

    In order for a test and trace operation to be successful 80% of identified close contacts need to be contacted and told to self-isolate. Performance figures released on 22 October 2020 show NHS Test and Trace is attaining 59.6%. The Government claims 300,000 Covid-19 tests are taking place daily and that daily figure will soon reach 500,000. Even if we all believe these figures, what’s the point if 80%+ timely contact tracing and self-isolation isn’t happening?

    Only 15.1% of those tested received test results within 24 hours. In June 2020 Prime Minister Johnson said he wanted 100% test results within 24 hours. 7.1 % of those tested were found to be Covid-19 positive – the highest figure yet.

    Seemingly one of the Government’s approaches to problem solving is to throw much more money at the problem. Briefly an advertisement lingered in the public domain searching for a new boss to ’deliver Trace operations’. The recruitment agency Quast’s advertisement stated its client (DHSC)  was offering £2,000/day (£520,000/year?)

    ‘The Guardian’ on 28 October 2020 revealed that 18 year olds with no clinical experience or knowledge are now working as ‘skilled contact tracers’ for Serco. They were recently ‘upskilled’ to perform this role. They are all being paid minimum wage of £6.45/hour. Whistle blowers have reported unskilled teenagers in tears and having panic attacks as they struggle to perform tasks such as like public health risk assessments.

    Professor Allyson Pollock has yet again exposed one of the key failings of the NHS Test and Trace undertaking. This was the Government’s decision to take testing out of public health services and Local Authorities. This overlooked the importance of clinical input, clinical oversight, clinical integration and statutory disease notification.

    NHS North West London (NWL) Finally Persuades West London CCG to Join the Single Regional CCG 

    ‘Health Service Journal’ has reported that although GPs in Kensington, Chelsea and Westminster voted against the merger of local CCGS in September 2020, in October 2020 they changed their minds. The NWL CCG will be the largest in England with 2.5 million patients and a 2020/21 budget of £4.2 billion. By April 2021 there will be just 5 CCGs in London. In 2019 there were 32 CCGs.

    Discover What the Covid-19 Infection Rate is in Your Neighbourhood

    Just type in your post code at:

    https://coronavirus-staging.data.go.uk

    To give you an idea of the range of rates throughout England, Blackburn with Darwen is one of the highest at 752.5/100,000 people and the lowest includes Somerset Wilton at 44.9/100,000.

    Eric Leach

    Comments Off on Our NHS in Crisis Issue: 110

    What happened during the first wave of Coronavirus and what can be done about it

    In the first wave of the Coronavirus pandemic, mortality rates for people in care homes were shockingly high. Many people living in residential care and nursing homes have cognitive impairments that make it hard for them to agree to their living conditions. In the spring and summer of this year, rights-based legal safeguards designed to protect people seem to have been ignored or set aside. The NHS and adult social care services are currently bracing themselves for a second wave. This article asks whether the safeguards are likely to be more robust this time around, and what can be done to ensure people’s rights are upheld in the future.

    ***

    According to the Office for National Statistics, there were 19,394 Covid-related deaths among care home residents between 2/3/20 and 12/6/20. About half the people in this group were recorded as having a pre-existing condition of dementia. Many will have been assessed as not having the mental capacity to decide where to live, and consequently should have been subject to Deprivation of Liberty Safeguards (DOLS).

    DOLS were introduced in 2009 after a landmark case in the European Court of Human Rights. Deprivations of liberty can be authorised by local authorities where they are proportionate, where there is no reasonable alternative, and critically where they are in people’s best interests. Local authorities have always lacked the resources to process applications, and backlogs began to build up as soon as the safeguards were introduced. Another legal ruling in 2014 held that many more people were being deprived of their liberty than had initially been supposed, putting even more pressure on the system. In 2019 the law was amended to introduce a new, speedier system, though this was contentious because it allowed care home managers a greater role in deciding whether deprivations were necessary or proportionate. This had been due to come in this month (October 2020), but implementation has now been put back to April 2022.

    During the first wave of the pandemic, the larger numbers of people moving into care homes should have resulted in a bigger figure for DOLS applications. Instead, the Care Quality Commission (CQC) recorded a 31% reduction in DOLS applications between April and June 2020 compared to 2019. It seems that the requirement to ensure that restrictions were in people’s ‘best interests’ was being quietly ignored. As well as considering the rights of the 25,000 or so people who were discharged from hospital to care homes with Coronavirus, it’s also important to consider the risks to the much larger number who were already resident. As care home staff struggled to prevent cross-contamination with inadequate PPE and high levels of staff sickness, many residents were confined to their rooms in accordance with government advice. The Mental Capacity Act 2005 may only be used to confine people in their best interests; where the deprivation is for public health purposes different provisions should have been used. Research by Dr Lucy Series showed that public health provisions were only applied a handful of times. The point here is not to second-guess the actions of staff who were clearly doing their best to manage under very difficult circumstances, but to ask ‘What’s the point of legal safeguards if they can just be ignored?’.

    In June the Equality and Human Rights Commission recommended that  the “ … Government should urgently undertake or commission a review into deaths in care homes during the pandemic, in line with its equality and human rights obligations…”. One would have expected that in the pause afforded after the first wave of infections, lessons would have been learned and changes made.  Instead we have an adult social care winter plan that promises (but has not yet developed) a “…designation scheme with the CQC for premises that are safe for people leaving hospital who have tested positive or are awaiting a test result.” It seems that the government is anticipating that people with the virus will be discharged into care homes, but a process for this to be safely managed is not yet in place. At the same time revised guidance that suggests that where new restrictions are imposed to prevent cross-infection “…in many cases [they] will not be…” new Deprivations of Liberty. However, considering the significantly greater risk of mortality under these circumstances, it seems at least reasonable to question whether the original judgements about what is in a person’s best interests would still be valid.

    ***

    The specific issue of DOLS is one of a large number where human rights seem to have been set aside during the initial Coronavirus outbreak. A report from Amnesty International published earlier this week found that the “…UK government, national agencies, and local-level bodies have taken decisions and adopted policies during the COVID-19 pandemic that have directly violated the human rights of older residents of care homes in England—notably their right to life, their right to health, and their right to non-discrimination.” Early on in the Pandemic there was concern that the frailty scale being used to decide whether people would get life-saving treatment was being used inappropriately with younger disabled groups, leading DHSC to issue urgent ‘clarification’. Last week the CQC was asked by DHSC to review the way that Do Not Attempt Resuscitation (DNAR) notices were used by clinicians. ONS data re-analysed by Prof. Chris Hatton shows in-patients with autism and learning disabilities were subjected to more restraints during the pandemic. Organisations such as Inclusion London, Inclusion Scotland and Disability Rights UK have highlighted linked concerns among other groups of disabled people. During the outbreak the majority of disabled people experienced difficulties accessing basic care, medicines and food. Many of these organisations have joined the EHRC and Amnesty in calling for an inquiry into the events of this year, and ultimately for stronger legal guarantees.

    Another important lesson relates to funding. The lack of social work capacity for DOLS authorisations, wider under-staffing and poor pay in the care sector, and the absence of alternatives to ‘congregate’ care have all contributed to the events described in this article. Adult social care services have been subjected to growing demands and reduced resources for over a decade. Why is it that vital local social care services are still facing massive financial shortfalls at the same time that central government is putting record sums into the NHS and privatised test-and-trace services? An urgent solution to funding in adult social care is also a necessary component of any solution. Many argue that this will only be politically viable when social care is seen not as a destination but as a vehicle for helping the people we are and the people we love to lead rich and full lives. These three strands – a brighter vision, a new financial solution, and stronger support for human rights – can form a common ground for campaigning and activism that can help us future-proof social care against similar crises in the future.

    Jon Hyslop, Oxfordshire Branch, 19/10/20

    3 Comments

    Yorkshire Socialist Health Association

    Command and Control Management:

    The Deadly Embodiment of Neo-Liberalism at work in the Public Sector

    John and Joe Carlisle, Mad Management[1]

    Although the Command and Control style of management is a fairly modern phenomenon, like all ideas, its roots go much further back, to a very dominant model of how to discipline and organise institutions. The philosopher Michael Foucault famously uses 18th Century Utilitarian philosopher Jeremy Bentham’s panopticon as a model for how a modern disciplinary society seeks to at all times to survey, or at least give the possibility of surveillance, its populace. The panopticon is a surveillance structure originally designed by Bentham for prisons but reproducible in any environment. The centre is occupied by a watchman who cannot be seen but who is surrounded in the round by the cells or workplaces of those he surveys. Each in their own compartmentalized sections the watchman, or manager, can see everything the prisoners do. As Foucault describes ‘[t]hey are like so many cages, so many small theatres, in which each actor is alone, perfectly individualized and constantly visible.’[2]

    Foucault rightly saw ‘panopticism’ as a paradigm through which individuals could be measured, assessed, marked and surveilled; it was not simply a design for a prison but a “how to” command and control for a whole variety of institutions from schools, hospitals and factories. It is worth quoting Foucault again, this time at length, as he describes the consequences of such a model:

    He is seen, but he does not see; he is the object of information, never a subject in communication… if they are workers, there are no disorders, no theft, no coalitions, none of those distractions that slow down the rate of work, make it less perfect or cause accidents. The crowd, a compact mass, a locus of multiple exchanges, individualities merging together, a collective effect, is abolished and replaced by a collection of separated individualities. From the point of view of the guardian, it is replaced by a multiplicity that can be numbered and supervised. 

    This top down model of designing the workplace was explicitly compatible with industrialization where work was broken down into small repetitive actions that can easily be measured and codified. What is harder to understand is why the model was placed upon all forms of work. Why do so many managers insist upon forcing this model onto industries, such as service, which it does not fit, and more tragically, why use it as the model for management in public services?

    It is now common for most people who work now to have a sense of being monitored. Whether through the ubiquitous CCTV camera, which now often can record audio, to electronic clock ins,’ recordings of all phone calls made in a call centres or on workphones, targets to be hit, milometers which time how long a delivery takes to go from A to B, to IPad’s whose programs must followed to the letter. What this produces is an abundance of data, a mountain of information which can be turned into charts, graphs, and reports. This gives the manager a great sense of control; to him nothing is hidden.

    Except of course a lot is hidden. Data by its very nature hides vast amounts of knowledge. The time it takes to get from A to B does not reveal that the final stage may add 20 mins because there is nowhere to park the lorry. The failure to reach the target may simply reveal the arbitrary nature of the target. In data the whole complexity of the human world is erased, flattened out into a spreadsheet, and the manager ends up mistaking the map for the terrain.

    Not only does it give the illusion of knowledge but command and control management style doesn’t work.  It makes waste rather than reducing it. This article will argue that it is an empirical fact that these modes of supervision fail to achieve what they claim to. Systems thinking is a far more effective way of improving organizations, and ironically, it has the data to back it up.

     Systems Thinking

     In 2003 Professor John Seddon published Freedom from Command and Control. [3] It caused quite a stir, demolishing most of the principles upon which the government had based its efficiency drive – which later morphed into wholly inappropriate and damaging austerity policies. It refuted the top down principle of leadership that is implicit in the New Public Management (NPM), which is a promoter of what Seddon calls ‘the management factory’: ‘The management factory manages inventories, scheduling, planning, reporting and so on. It sets the budgets and targets. It is a place that works with information that is abstracted from work. Because of that it can have a phenomenally negative impact on the sustainability of the enterprise.”

    The case studies gave irrefutable evidence of the damage caused by this neo-liberal mechanism in the public sector. Seddon’s solution was systems thinking as expanded in his next book, Systems Thinking in the Public Sector.[4] Here example after example illustrated the waste caused by NPM, especially as advocated by the likes of Barber (targets etc.) and Varney (shared services – see appendix)

    The research and analysis conducted by Professor John Seddon, which has looked at reasons for diseconomies of scale specifically in service organisations, fundamentally challenges the ‘Command and Control’ logics that underpin much of the public sector. Instead case study after case study confirms that concepts such as ‘designing against demand’, ‘removing failure demand’ deliver outstanding success  , while the typical drive to standardisation and specialisation of function results in inappropriate services being delivered, resulting in turn in escalating monitoring, management and correction costs.

    This, however, requires a change of thinking about how organisations work best in this the 21st century. Over a hundred years ago the workforce was only one generation removed from an industrial culture. Their understanding of industrial production and its organisation was very limited. Consequently even the best designers of organisations, e.g. Henry Ford, the Quakers, Cadburys, Rowntree’s and Clarks, were at best paternal, and at worst, reductionist pragmatists, i.e. treating workers as intelligent tools. However, even the latter did not mean not trusting them or attempting to look after them. After all, Henry Ford doubled the wages of his workforce overnight and refused to allow women to labour after 5pm so they could look after their families. He was also sued by his major shareholder for doubling his workers’ wages at the expense of dividends. The shareholder won.

    Today, we have a workforce that is literate and numerate and is at home with modern organisations, BUT are managed as those of 100 years ago. Why is this? The reason is the Command and Control style is more comfortable for those leaders whose upbringing (conditioning) and training at Business Schools has brainwashed them into feeling that being in charge means taking control. As they cannot be everywhere they therefore use measuring as a proxy for their physical presence. This usually translates into columns of comparative data or run charts, tick boxes compliance, and often targets to be reached as evidence of success of failure.

    So, who is the guardian in the panopticon? It is HR. In many public sector organisations HR has seized this opportunity to become the enforcer of compliance for the board. Rejoicing in their power they have abandoned their traditional role of looking after the workforce and now “guard” it.

    Politicians are entranced by these governance measures. They can conceive of nothing more confidence boosting than setting targets for, e.g. hospital waits, housing allocations, repairs completed. Their mental model is captured in the Table 1, below, in the left hand column. It is informed by their neo-liberal mindset, something they have imbibed from exposure to the right wing press; the fascination with material success, for example Peter Mandelson, playmaker of the Labour party said twenty years ago that he was “intensely relaxed about people getting filthy rich as long as they pay their taxes”; privatisation continues even though it is clearly an utter failure; and cost-cutting  and targets are the first knee jerk reactions to perceived public sector overspend.

    But there is another way. It comes in the form of a System of Profound Knowledge, first propounded by the great management philosopher, Dr W. Edwards Deming, whose principles are best presented in the work of Professor John Seddon, head of Vanguard.

    The Seddon Vanguard model, constructed from his research into effective organisations is the right hand column (Table 1).

    Table 1. The two conflicting models of management

    The question is why, in particular do UK politicians favour the Command and Control model? Our theory is that it is the “control” element that matters most – and, which has caused the most waste, and managers and politicians in particular are comforted by the illusion of control even when it clearly causes so much damage to people and resources as the examples below illustrate. [5]

    • Western Australia’s Department of Treasury and Finance Shared Service Centre promised savings of $56 million, but incurred costs of $401 million.
    • A National Audit Office report said that the UK Research Councils project was due to be completed by

    December 2009 at a cost of £79 million. But, in reality, it was not completed until March 2011, at a cost of £130 million.

    • The Department for Transport’s Shared Services, initially forecast to save £57m, is now estimated to cost the taxpayer £170m, a failure in management that the House of Commons Public Accounts Committee described as a display of ‘stupendous incompetence’

    Covid-19 has made the flaws are even more obvious. That greatest of all control freakery, the centralising state, has been shown for disaster that it is. The Health Secretary has kept control of all the testing and tracing administered from the centre, and it is failing at every level. The report from the Independent SAGE, a group of 12 leading scientists headed by former UK Government chief scientific advisor, David King, said the governments test, track and trace system is not “fit for purpose”.

    The government’s current approach to this system, including the contact-tracing app, is “severely constrained by lack of coordination, lack of trust, lack of evidence of utility and centralisation”, it adds. “The effective operation of this subsystem is also complicated by the apparent failure of the app that was designed to facilitate identification of contacts of those who have Covid-19” (Digital Health, June 16, 2020). We are talking here about thousands of British lives and further damage to a reeling economy.

    Dr W Edwards Deming summed it up perfectly: “Most people imagine that the present style of management has always existed and is a fixture. Actually, it is a modern invention – a prison created by the way in which people interact.”  He then asked the question:

     How do we achieve quality? Which of the following is the answer? Automation, new machinery, more computers, gadgets, hard work, best efforts, merit system with annual appraisal, make everybody accountable, management by objectives, management by results, rank people, rank teams, divisions, etc., reward the top performers, punish low performers, more statistical quality control, more inspection, establish an office of quality, appoint someone to be in charge of quality, incentive pay, work standards, zero defects, meet specifications, and motivate people.”[6]

    Answer: None of the above. (Will someone please tell our politicians.)

    All of the ideas above for achieving quality try to shift the responsibility from management. Quality is the responsibility of management. It cannot be delegated. What is needed is profound knowledge. A transformation of management is required, and to do that a transformation of thinking is required – actually the neo-liberal paradigm is so entrenched that that nothing less than metanoia (a total change of heart and mind) is needed.

    When this transformation happens almost miraculous levels of performance occur. For example, when left to the medical staff only, the level of delayed bed days fell from over 12,000 per month to under 6000 in a year (2017/2018) – an over 50% reduction! Much less command and control leads to much more economic and effective activity. It is time all the politicians learned to trust their public servants much more, and abandon the illusion of control foisted on them by neo-liberal ideologists from Labour and Conservatives. It is a political thing, not a party thing. The whole system of government must be overhauled.


    References

    [1] https://jcashbyblog.wordpress.com

    [2]Michel Foucault, Discipline and Punish, trans. A. Sheridan (Vintage books, New York, 1995) p. 200

    [3] Seddon 2003 ‘Freedom from Command and Control’ Vanguard Education

    [4] Seddon 2008 ‘Systems thinking in the Public Sector’ Triarchy: Axminster

    [5] John Seddon 2012 submission to the Local Government and Regeneration Committee – Public Sector reform and Local Government. 2012

    [6] Deming, W.E. (1993) Out of the Crisis, MIT: Cambridge

     

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    There has been too much reliance on the private sector when it comes to laboratory testing for coronavirus and not enough investment in long-established NHS facilities, Unite, Britain and Ireland’s largest union, said today (Wednesday 16 September).
    Unite’s stance is underpinned by its Biomedical Scientist Covid-19 survey, launched today, which highlights the under-use of NHS science facilities and resources as the crisis over the nationwide gaps in the Covid-19 testing regime escalates.
    The survey reveals Unite members’ unhappiness at the government’s reliance and priority given to the seven Lighthouse Laboratories, with private sector involvement, while long-established NHS facilities are being apparently sidelined when it comes to investment.
    The report is being sent to health and social care secretary Matt Hancock, and the chair of the Commons health and social care select committee Jeremy Hunt, as well as MPs.
    The survey said: Concerns about under-utilisation of NHS resources were matched by concerns around the introduction of the new Lighthouse Laboratories and the impact this was having on NHS services.
    “Broadly these concerns focused on the quality of services provided, the diversion of resources from the public sector and the decision making, and transparency process used to commission these new laboratories.
    Healthcare science staff and their trade unions have been left in the dark regarding these processes.”
    More than 85 per cent of the survey’s respondents agreed that there was concern about the service quality from the Lighthouse Laboratories and over 90 per cent concurred that there were worries about the transparency and contracting arrangements for these laboratories.
    In contrast, only 38 per cent said their NHS laboratories were working at full capacity, but there was near unanimous support for further investment in NHS labs, so they are well-placed to undertake the mass testing of millions envisaged by Operation Moonshot.
    Unite said that Operation Moonshot should not become ‘an ill-deserved pay day bonanza’ for private healthcare companies which had fallen short during the pandemic to the extent that they have asked the NHS to help out.
    Unite lead officer for healthcare science Gary Owen said: “The government’s obsession with involving the private sector in the Covid-19 ‘trace and test’ regime has been shown to be flawed and misguided, as more and more people report difficulties in trying to get a test near to their home.
    “If ministers have learnt any lessons from Covid-19 it should be that the NHS, with the right level of investment, is best placed to provide laboratory testing for such a global pandemic as we are currently going through.”
    Chair of the Unite healthcare science committee Ian Evans said: “Long-established NHS laboratories with a wealth of professional experience built up over decades appear to have been marginalised in the battle against coronavirus – this has been a huge mistake.”

    The report can be accessed via:

    https://unitetheunion.org/media/3331/9199_biomed-scientists_survey_summer2020_final-digital.pdf

    The survey was distributed on two dates in June by email to all Unite members within healthcare science. This snapshot survey generated 388 responses from across the UK.

    Unite senior communications officer Shaun Noble

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    This is SHA Scotland Secretary Dave Watson’s contribution to a Jimmy Reid Foundation paper; ‘Reconstructing Scotland after COVID-19: learning further lessons from the pandemic.’

    A Scottish Care Service

    Even before the pandemic, it was clear that the social care system in Scotland was in urgent need of reform. The current system is underfunded, lacks capacity, and has major workforce recruitment and retention problems with fragmented delivery through a discredited commissioning process. When former Conservative ministers are openly talking about the nationalisation of care homes, there is widespread recognition that there is a problem (even if not agreement on what should be done to solve the issue). The system is not just failing those who need social care but is also damaging the NHS with over half a million hospital bed days lost every year because of delayed discharges at the cost of £120m. These problems have been magnified during the pandemic. The lack of Personal Protective Equipment (PPE), inadequate testing, minimal sick pay, and use of agency staff, have all contributed to the tragic deaths in care homes and amongst social care staff. Care at home has also been impacted with care packages reduced or abandoned. Informal carers have all too often been left to pick up the pieces.

    The concept of a (national) Scottish Care Service (SCS) as part of the solution is not a new one. It has been Scottish Labour policy for a number of years, most recently as a 2019 General Election manifesto commitment (see p35 here). My own organisation, the Social Health Association, outlined the idea in its recent social care consultation paper. And, UNISON Scotland has recently published what it describes as a ‘road map’ towards the creation of a national care service. But while there is growing support for the principle of a Scottish Care Service, many in the sector have reasonably asked what it means in practice.

    There seems to be a consensus in favour of a national framework rather than a service delivery organisation or making it part of NHS Scotland, not least to recognise the different models of care. But that leaves open what the SCS would undertake directly and what would be the governance arrangements. A national framework approach must end the current marketisation of social care. It could set consistent standards, contracts and charges for services not covered by free personal care. Most importantly, it would include a statutory workforce forum to set minimum terms and conditions, organise effective workforce planning and put a new focus on training and professionalism.

    On governance, the usual approach would be to create a new Non-Departmental Public Body (NDPB). This would leave the SCS with a similar democratic deficit to NHS Scotland and would undoubtedly be populated with the ‘usual suspects’ by the ministers who make the appointments. As the service will be delivered locally, another approach would be to create a joint board from councils across Scotland. This was a solution UNISON Scotland proposed for police and fire, which had the added advantage of keeping the VAT exemptions. The joint board could have places for relevant stakeholders, including users and worker providers.

    A national service would also need to address regulation. The Care Inspectorate’s ‘light touch’ response to rising complaints has highlighted the need for reform. In fairness, it has been constrained by the Scottish Government’s own ‘Better Regulation’ code, together with inadequate powers and resources. There would also need to be a review of workforce regulation currently administered by the Scottish Social Services Council and UK professional regulatory bodies.

    If the service is going to be delivered locally, this leaves open the question of local governance and ownership. As the Accounts Commission noted in its annual overview, the current system of Integrated Joint Boards (IJBs) has struggled to deliver integration or a shift in spending from hospitals to community care. There have been many attempts to improve integration in Scotland since the joint finance arrangements of the 1970s and all have struggled. It may be that this iteration will eventually deliver, but many will argue that it requires stronger democratic accountability to make difficult decisions, and that means a bigger role for councils. This happens in other parts of Europe, but even here, they have not always shifted resources from hospitals to community services.

    Greater integration does not require staffing integration. Professional barriers have been broken down in recent years, and joint teams have shown that they can work effectively together, particularly when physically working together in community hubs. A huge staffing reorganisation would create stasis, just at the time when we need to free up staff to innovate. When IJBs were created, I – as a UNISON Scotland official – wrote a workforce framework, which would have addressed many of the current problems. Sadly, workforce issues were largely ignored at the time.

    The fragmentation in service delivery is a significant problem that does need to be addressed with more than one thousand care at home providers, and the scandal of care home firms registered in tax havens. In the short-term, the pandemic has highlighted the need for greater coordination on issues like procurement. Abolishing the market, standard contracts and common workforce standards will help shift resources to the front-line. In the medium-term, there should be greater common ownership, particularly in residential care.

    Common ownership does not preclude innovative voluntary sector operators who can meet the new standards as the best in the sector already do. The private sector likes to make a false link between personalised care and marketisation. All care should be personalised, and that requires a range of services, not a range of ownership models. Local delivery should also be about greater innovation in service delivery, trying new models of care that integrate people with care needs into communities.

    Finally, there is the tricky issue of funding. In England, the issue has at least been considered in the Dilnott Report, although it was overly focused on protecting assets. In Scotland, we cannot simply hope for the Barnett consequentials of reform in England to plug the current funding gap, let alone future demographic pressures. It requires a mature conversation with citizens about taxation. If we want to go further and fund care on the same basis as the NHS, then the conversation shifts to proposals like the former health minister Andy Burnham’s care levy, which involved a form of inheritance tax. Calling it and similar plans a ‘death tax’ is not a mature conversation.

    The creation of a Scottish Care Service is an idea which has come of age. Turning it from a concept into a practical solution requires more work and some difficult conversations. If we are to ‘Build Back Better’, as the Tories implore, an integrated health and care service, with national standards and local delivery should be the highest priority.

    Dave Watson, Secretary of the Socialist Health Association Scotland
    www.shascotland.org

    sha_social_care_reform

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    Today HIV i-Base (where I work part-time) and the UK-CAB (of which I’m a member) joined with more than 70 other organisations sending a joint statement to the Prime Minister, the Secretary of State for Health, and the interim leadership of Public Health England regarding our concerns of the restructuring of public health in England.

    Over 70 health organisations unite to raise serious concerns with Government about plans to reorganise the public health system

    Today over 70 health organisations and alliances have sent a joint statement to the Prime Minister, the Secretary of State for Health, and the interim leadership of Public Health England, raising serious concerns about the reorganisation of public health now underway. This follows recent announcements that PHE will cease to exist by April next year and be replaced by the National Institute of Health Protection.

    The statement is endorsed by a wide range of leading health organisations, including the Association of Directors of Public Health, the Faculty of Public Health, the Royal Society for Public Health, the Academy of Medical Royal Colleges, the BMA, the SPECTRUM public health research collaboration, the Smokefree Action Coalition and the Richmond Group of health and care charities. The statement warns that:

    “Reorganisation risks fragmentation across different risk factors and between health protection and health improvement. Organisational change is difficult and can be damaging at the best of times and these are not the best of times. A seamless transition from the current to the new system is essential.”

    While recognising that there are opportunities:

    “There are opportunities from this re-organisation to improve on current delivery, but only if there is greater investment combined with an emphasis on deepening expertise, improving co-ordination and strengthening accountability.”

    The statement, launched today in a letter to the BMJ from key signatories sets out the principles which all agree must underpin the new health improvement system. This includes the need for renewed investment into public health to address the years of cuts the sector has seen, an interconnected approach with the right infrastructure and expertise to support national, regional and local delivery; and the need to sustain local government system leadership at local level, while strengthening co-ordination with the NHS.

    Dr Nick Hopkinson, a respiratory specialist at Imperial College London, chair of Action on Smoking and Health, speaking on behalf of the Smokefree Action Coalition as a signatory to the letter said:

    “We are in a state of public health emergency because of COVID-19, and system reorganisation at this time brings with it great risks, as well as opportunities. That is why the public health community has come together to set out for Government the principles that we all agree must underpin any reorganisation of the health improvement and wider functions of Public Health England (PHE). If we are to recover from the global pandemic and recession, health improvement is not a ‘nice to have’ but an essential component of a successful response to the challenges we face.”

    Professor Maggie Rae, President of the Faculty of Public Health, signatory to the BMJ letter, said:

    “Reorganisation of Public Health England (PHE) brings with it a real risk that some of the critical functions of PHE will be ignored. The pandemic has shone the light on the health inequalities that exist in the country and it is clear that those with the poorest health have been hit hardest. Scaling up, not down, the health improvement functions of PHE is a prerequisite if the Government is to deliver on its commitments to ‘level up’ society; increase disability-free life years significantly, while reducing inequalities; to improve mental health; increase physical activity; reduce obesity and alcohol harm; and to end smoking. Ensuring there is adequate funding, a robust infrastructure and sufficient public health expertise to deliver at national, regional and local level, is fundamental.”

    Professor Linda Bauld, Chair of Public Health at the University of Edinburgh and Director of public health research consortium SPECTRUM, signatory to the BMJ letter said:

    “While COVID-19 is a pressing emergency, the truth is that chronic non-infectious diseases are still overwhelmingly responsible for preventable death and disease in this country. What’s more those with the poorest existing health have the worst outcomes from COVID-19. A future public health system must be robust enough to protect us from the threats posed by both infectious and non-infectious diseases.”

    Joint statement to the Government on Public Health Reorganisation. Link to statement and list of signatories https://smokefreeaction.org.uk/phehealthimprov/

    Link to BMJ letter: Rapid Response: Joint statement to the Government on Public Health Reorganisation: https://www.bmj.com/content/370/bmj.m3263/rr-1

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    The Local Government Association, on behalf the broad leadership of the social care sector including the Association of Directors of Social Services, has published a set of 7 principles to guide the future of adult social care post Covid. But they show the sector’s leadership continuing to be high on rhetoric, but empty on substance. They are bankrupt of ideas to make the rhetoric a reality.

    The 7 principles talk, for the umpteenth time, of social care needing to be based on ‘what works for people, not what works for systems or structures’. They seek to emulate the person centredness that makes the NHS so valued by the public. People trust that when they present symptoms to an NHS clinician the diagnosis and treatment will be based solely on the clinician’s knowledge of what is wrong and what is possible. It would not even occur to the person that the determination of their diagnosis and decisions about the treatment options will be referred upward to a manager, least of all to a manager whose primary task is to manage the budget.

    But, for reasons set out in my recent blog, this is exactly what happens in social care. At the individual level, while need precedes resources in health care, resource precedes need in social care. It’s an arrangement that serves very well the political expedients of keeping spend precisely to budget while denying the existence of any funding gap. The sector’s leadership, sadly and only too willingly, obliges.

    So sector leaders are left yet again repeating mantras with a long record of failure. The history is lamentable.

    Following the failure of the Community Care strategy of the 1990’s to make social care ‘needs led’, the personalisation strategy was launched in 2008 with personal budgets the centre piece. ‘Up-front’ allocations of money would empower service users to purchase their own support package, the ultimate in person centredness. Bu it quickly became apparent that up-front allocations would not happen. Completely impracticable and ignored by the Care Act ‘up-front’ allocations became ‘indicative’ only and thus tokenistic. In 2012, Think Local Act Personal, the organisation charged by Government with leading implementation of the strategy, issued a series on exhortations to practitioners and councils under the banner Making It Real.

    The irony in the implicit message that personal budgets had completely failed to ‘make it real’ was lost on the sector’s leaders. Inevitably, Making It Real had no impact. TLAP duly issued a second iteration of Making It Real in 2018. It too has had no impact. And so to the present and the 7 principles amount to yet a third exhortation to ‘make it real’.

    Exhortations to practitioners and councils to deliver ‘what works for people’ are hopeless in the face of underlying, powerful systemic forces that ensure the system’s priority is to work to sustain itself.

    What of the future for social care – integration with the NHS?

    It’s hard to imagine anyone taking the analysis and remedies of sector leaders seriously. This is not just because of the self harm in exposing the bankruptcy in their own ideas. Covid’s exposure of the impoverishment of social care invites questions of the leadership Councils have provided over the decades. Is it really just about government under-funding? How soon, if not already, before Councils are seen as a busted flush?

    Signs are pointing to integration with the NHS as the political solution. But with social care in its present state, that would be a disaster for both services and the older and disabled people who rely on them. The NHS is at its best delivering clinical care to deliver best possible health. When it moves beyond that into care, its record is even more lamentable than that of local authorities. The bureaucratic opaqueness and gross inequity of Continuing Health Care bears witness to that. A weak and unreformed social care service risks being reduced to little more than a servant to health objectives. This would sound the death knell of the ambition of social care to be the driver of our older and disabled citizens being supported to lead the fulfilling and dignified lives they are capable of.

     

    Colin Slasberg – former Assistant Director of Social Care and Independent Consultant in Social Care.

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